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Yim SH, Lorenz H, Salkovskis P. The Effectiveness and Feasibility of Psychological Interventions for Populations Under Ongoing Threat: A Systematic Review. TRAUMA, VIOLENCE & ABUSE 2024; 25:577-592. [PMID: 36861772 PMCID: PMC10666526 DOI: 10.1177/15248380231156198] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Current views of psychological therapies for trauma typically assume the traumatic event to be in the past. Yet, individuals who live in contexts of ongoing organized violence or experience intimate partner violence (IPV) may continue to be (re)exposed to related traumatic events or have realistic fears of their recurrence. This systematic review considers the effectiveness, feasibility, and adaptations of psychological interventions for individuals living with ongoing threat. PsychINFO, MEDLINE, and EMBASE were searched for articles that examined psychological interventions in contexts of ongoing threat of either IPV or organized violence and used trauma-related outcome measures. The search was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data on study population, ongoing threat setting and design, intervention components, evaluation methods, and outcomes were extracted, and study quality was assessed using the Mixed-Method Appraisal Tool. Eighteen papers featuring 15 trials were included (12 on organized violence and 3 on IPV). For organized violence, most studies showed moderate to large effects in reducing trauma-related symptoms when compared to waitlists. For IPV, findings were varied. Most studies made adaptations related to culture and ongoing threat and found that providing psychological interventions was feasible. The findings, albeit preliminary with mixed methodological quality, showed psychological treatments can be beneficial and should not be withheld in the context of ongoing organized violence and IPV. Clinical and research recommendations are discussed.
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Affiliation(s)
- See Heng Yim
- University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
| | - Hjördis Lorenz
- University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
| | - Paul Salkovskis
- University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Oxford, UK
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2
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Breaking the cycles of violence with narrative exposure: Development and feasibility of NETfacts, a community-based intervention for populations living under continuous threat. PLoS One 2022; 17:e0275421. [PMID: 36534649 PMCID: PMC9762574 DOI: 10.1371/journal.pone.0275421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 08/10/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Interpersonal violence damages mental health and frequently leads to aggressive defence strategies. If survivors are subsequently blamed for the events, both consequences worsen. Stigma flourishes, especially when survivors are silenced so that details of the trauma remain unknown. Breaking the secrecy both at the individual and collective level is key to enable the healing and reconciliation of individuals and communities living under continuous threat. METHOD The NETfacts health system is a stepped care model with three components: (1) Narrative Exposure Therapy (NET), an evidence-based trauma therapy that includes survivor testimony (2) NET for Forensic Offender Rehabilitation (FORNET) acknowledges that perpetrators are frequently also victims and assists in reducing aggression and the attraction to violence, and (3) a community intervention disseminating and discussing Facts derived from NET treatment (NETfacts) to challenge the collective avoidance of atrocities and other traumatic material. The intervention was piloted in a community with 497 adult residents in Eastern Democratic Republic of Congo. The willingness of clients to consent to sharing their anonymised testimonies (with a focus on sexual violence survivors and ex-combatants) was investigated, together with other components of feasibility including security and clinical safety, extent of support of respected local authorities and participation rates. As secondary outcomes, clinical and social measures were assessed before and post NETfacts among 200 village residents of whom 160 self-enrolled and 40 had not participated in any form of treatment. RESULTS Implementation was feasible with 248 clients from a partner project giving consent to use their testimonies and high support of respected local authorities and participation rates (56% of residents self-enrolled in NETfacts). Immediate beneficial effects were shown for posttraumatic stress and rejection of rape myths among NETfacts participants who experienced multiple traumatic events in their own past. Attitudes towards ex-combatants improved and the perceived lack of social acknowledgement after trauma increased independent from participation. No significant change was observed for depressive symptoms. CONCLUSION NETfacts is a feasible and promising approach to challenge the culture of secrecy surrounding trauma, suppression and social exclusion. Long term effectiveness requires further evaluation.
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Siehl S, Wilhelms L, Crombach A. Commentary on Raghuraman et al. (2021). On the Long-Term Efficacy and Effectiveness of Narrative Exposure Therapy. Front Psychol 2021; 12:771958. [PMID: 34819901 PMCID: PMC8606553 DOI: 10.3389/fpsyg.2021.771958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/08/2021] [Indexed: 12/31/2022] Open
Affiliation(s)
- Sebastian Siehl
- Institute of Medical Psychology and Medical Sociology, University Medical Center Schleswig-Holstein, Kiel University, Kiel, Germany.,Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany.,Non-governmental Organization vivo International e.V., Konstanz, Germany
| | - Laura Wilhelms
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
| | - Anselm Crombach
- Non-governmental Organization vivo International e.V., Konstanz, Germany.,Department of Psychology, Clinical Psychology and Psychotherapy for Children and Adolescents at the University of Saarland, Saarbrücken, Germany.,Department of Psychology at the University of Konstanz, Clinical Psychology, Kosntanz, Germany.,Non-governmental Organization Psychologues Sans Frontières, Bujumbura, Burundi.,Department of Clinical Psychology, Université Lumière de Bujumbura, Bujumbura, Burundi
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Carleial S, Nätt D, Unternährer E, Elbert T, Robjant K, Wilker S, Vukojevic V, Kolassa IT, Zeller AC, Koebach A. DNA methylation changes following narrative exposure therapy in a randomized controlled trial with female former child soldiers. Sci Rep 2021; 11:18493. [PMID: 34531495 PMCID: PMC8445994 DOI: 10.1038/s41598-021-98067-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 09/02/2021] [Indexed: 02/08/2023] Open
Abstract
The aftermath of traumatization lives on in the neural and epigenetic traces creating a momentum of affliction in the psychological and social realm. Can psychotherapy reorganise these memories through changes in DNA methylation signatures? Using a randomised controlled parallel group design, we examined methylome-wide changes in saliva samples of 84 female former child soldiers from Eastern DR Congo before and six months after Narrative Exposure Therapy. Treatment predicted differentially methylated positions (DMPs) related to ALCAM, RIPOR2, AFAP1 and MOCOS. In addition, treatment associations overlapped at gene level with baseline clinical and social outcomes. Treatment related DMPs are involved in memory formation-the key agent in trauma focused treatments-and enriched for molecular pathways commonly affected by trauma related disorders. Results were partially replicated in an independent sample of 53 female former child soldiers from Northern Uganda. Our results suggest a molecular impact of psychological treatment in women with war-related childhood trauma.Trial registration: Addressing Heightened Levels of Aggression in Traumatized Offenders With Psychotherapeutic Means (ClinicalTrials.gov Identifier: NCT02992561, 14/12/2016).
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Affiliation(s)
- Samuel Carleial
- grid.9811.10000 0001 0658 7699Department of Psychology, Centre for Psychiatry, University of Konstanz, Feuerstein-Strasse. 55, Haus 22, 78479 Konstanz, Germany
| | - Daniel Nätt
- grid.5640.70000 0001 2162 9922Division of Neurobiology, Department of Biomedical and Clinical Sciences, University of Linköping, Building 463, Room 12.023, Linköping, Sweden
| | - Eva Unternährer
- grid.9811.10000 0001 0658 7699Department of Psychology, Centre for Psychiatry, University of Konstanz, Feuerstein-Strasse. 55, Haus 22, 78479 Konstanz, Germany ,grid.6612.30000 0004 1937 0642Child- and Adolescent Research Department, Psychiatric University Hospitals Basel (UPK), University of Basel, Basel, Switzerland
| | - Thomas Elbert
- grid.9811.10000 0001 0658 7699Department of Psychology, Centre for Psychiatry, University of Konstanz, Feuerstein-Strasse. 55, Haus 22, 78479 Konstanz, Germany ,Vivo International E.V., Postbox 5108, 78430 Konstanz, Germany
| | - Katy Robjant
- Vivo International E.V., Postbox 5108, 78430 Konstanz, Germany
| | - Sarah Wilker
- Vivo International E.V., Postbox 5108, 78430 Konstanz, Germany ,grid.7491.b0000 0001 0944 9128Department of Psychology and Sports Science, University of Bielefeld, 33501 Bielefeld, Germany
| | - Vanja Vukojevic
- grid.6612.30000 0004 1937 0642Psychiatric University Clinics, Transfaculty Research Platform, University of Basel, Wilhelm Klein-Strasse 27, CH-4012 Basel, Switzerland
| | - Iris-Tatjana Kolassa
- Vivo International E.V., Postbox 5108, 78430 Konstanz, Germany ,grid.6582.90000 0004 1936 9748Department of Clinical and Biological Psychology, Institute of Psychology & Education, University of Ulm, Ulm University, Ulm, Germany
| | - Anja C. Zeller
- grid.9811.10000 0001 0658 7699Department of Psychology, Centre for Psychiatry, University of Konstanz, Feuerstein-Strasse. 55, Haus 22, 78479 Konstanz, Germany ,Vivo International E.V., Postbox 5108, 78430 Konstanz, Germany
| | - Anke Koebach
- grid.9811.10000 0001 0658 7699Department of Psychology, Centre for Psychiatry, University of Konstanz, Feuerstein-Strasse. 55, Haus 22, 78479 Konstanz, Germany ,Vivo International E.V., Postbox 5108, 78430 Konstanz, Germany
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Ennis N, Sijercic I, Monson CM. Trauma-focused cognitive-behavioral therapies for posttraumatic stress disorder under ongoing threat: A systematic review. Clin Psychol Rev 2021; 88:102049. [PMID: 34139653 DOI: 10.1016/j.cpr.2021.102049] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/18/2021] [Accepted: 05/25/2021] [Indexed: 11/26/2022]
Abstract
Some individuals with posttraumatic stress disorder (PTSD) are at elevated risk of reexposure to trauma during treatment. Trauma-focused cognitive-behavioral therapies (CBT) are recommended as first-line PTSD treatments but have generally been tested with exclusion criteria related to risk for trauma exposure. Therefore, there is limited knowledge on how to best treat individuals with PTSD under ongoing threat of reexposure. This paper systematically reviewed the effectiveness of CBTs for PTSD in individuals with ongoing threat of reexposure. Literature searches yielded 21 studies across samples at ongoing risk of war-related or community violence (n = 14), domestic violence (n = 5), and work-related traumatic events (n = 2). Medium to large effects were found from pre to posttreatment and compared with waitlist controls. There were mixed findings for domestic violence samples on long-term outcomes. Treatment adaptations focused on establishing relative safety and differentiating between realistic threat and generalized fear responses. Few studies examined whether ongoing threat influenced treatment outcomes or whether treatments were associated with adverse events. Thus, although the evidence is promising, conclusions cannot be firmly drawn about whether trauma-focused CBTs for PTSD are safe and effective for individuals under ongoing threat. Areas for further inquiry are outlined.
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Affiliation(s)
- Naomi Ennis
- Department of Psychology, Ryerson University, Canada; National Crime Victims Research & Treatment Center (NCVRTC), Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina.
| | - Iris Sijercic
- Department of Psychology, Ryerson University, Canada
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Loades ME, Read R, Smith L, Higson-Sweeney NT, Laffan A, Stallard P, Kessler D, Crawley E. How common are depression and anxiety in adolescents with chronic fatigue syndrome (CFS) and how should we screen for these mental health co-morbidities? A clinical cohort study. Eur Child Adolesc Psychiatry 2021; 30:1733-1743. [PMID: 32964335 PMCID: PMC8558286 DOI: 10.1007/s00787-020-01646-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 09/12/2020] [Indexed: 12/15/2022]
Abstract
Adolescents with Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) appear to be more likely to experience anxiety and/or depression using Patient Reported Outcome Measures (PROMs). However, we do not know how accurate these are at detecting problems in this patient group given the primary symptom of fatigue. We aimed to accurately determine the prevalence of anxiety/depression using gold-standard diagnostic interviews and evaluate the accuracy of PROMs measuring mood disorders in this patient group. We conducted a cross-sectional epidemiological study in a specialist tertiary paediatric CFS/ME service, England. The participants were164 12-18-year olds with clinician confirmed CFS/ME and their parents. The measures were a semi-structured diagnostic interview, the Kiddie Schedule for Affective Disorders and Schizophrenia, K-SADS, and questionnaires (Revised Children's Anxiety and Depression Scale, RCADS; Spence Children's Anxiety Scale, SCAS; Hospital Anxiety and Depression Scale, HADS). Parents completed the RCADS-P. 35% met the criteria for at least one common mental health problem. 20% had major depressive disorder, and 27% an anxiety disorder, with social anxiety and generalised anxiety being the most common. There was high co-morbidity, with 61% of those who were depressed also having at least one anxiety disorder. The questionnaires were moderately accurate (AUC > 0.7) at detecting clinically significant anxiety/depression, although only the RCADS-anxiety reached the predefined 0.8 sensitivity, 0.7 specificity target. Mental health problems are particularly common amongst adolescents with CFS/ME. Most screening tools were not sufficiently accurate in detecting clinically significant anxiety and depression, so these should be used with care in combination with thorough psychological/psychiatric assessment.
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Affiliation(s)
- Maria E Loades
- Department of Psychology, University of Bath, Bath, BA2 7AY, UK.
- Bristol Medical School, University of Bristol, Bristol, UK.
| | - Rebecca Read
- Department of Psychology, University of Bath, Bath, BA2 7AY, UK
| | - Lucie Smith
- Department of Psychology, University of Bath, Bath, BA2 7AY, UK
| | | | | | | | - David Kessler
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Esther Crawley
- Bristol Medical School, University of Bristol, Bristol, UK
- Royal United Hospital, Bath, UK
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Zeller AC, Conrad D, Schneider A, Behnke A, Pfeiffer A, Blum GF, Wilker S, Elbert T, Kolassa I. A combination of combat experience, early abduction, and severe traumatization fuels appetitive aggression and violence among abductees of rebel war in Northern Uganda. Aggress Behav 2020; 46:465-475. [PMID: 32643160 DOI: 10.1002/ab.21914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 11/10/2022]
Abstract
Individuals who perpetrate violence may likely perceive violence as appealing and infliction of violence to derive pleasure is termed as appetitive aggression. Individuals who were abducted as children into an armed group often experience a higher number of traumatic event types, that is traumatic load and are usually socialized in a violence-endorsing environment. This study aims to investigate the interaction between age at initial abduction with that of traumatic load, and their influence on appetitive aggression along with perpetration of violent acts by former members of an armed rebel group of both sexes. Semi-structured interviews were conducted among a target group of formerly abducted rebel-war survivors (including participants with and without combat experience) from Northern Uganda. Participants included 596 women and 570 men with N = 1,166 (Mage = 32.58, SDage = 9.76, range: 18-80 years). We conducted robust linear regression models to investigate the influence of age at initial abduction, traumatic load, combat experience, and biological sex on appetitive aggression as well as their perpetrated violent acts. Our study shows, appetitive aggression and the number of perpetrated violent acts were specifically increased in individuals who were abducted young, experienced several traumatic events in their lifetime, and with previous combat experience. For perpetrated violence men showed increased levels whereas for appetitive aggression the association was independent of biological sex. Therefore, early abducted individuals with a higher traumatic load, who have combat experience, need to be given special intervention to prevent any further violence.
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Affiliation(s)
- Anja C. Zeller
- Clinical Psychology and Neuropsychology, Department of Psychology University of Konstanz Konstanz Germany
- vivo international e.V. Konstanz Germany
| | - Daniela Conrad
- Clinical Psychology and Neuropsychology, Department of Psychology University of Konstanz Konstanz Germany
- Department of Clinical and Biological Psychology, Institute of Psychology and Education Ulm University Ulm Germany
| | - Anna Schneider
- vivo international e.V. Konstanz Germany
- Department of Clinical and Biological Psychology, Institute of Psychology and Education Ulm University Ulm Germany
| | - Alexander Behnke
- Department of Clinical and Biological Psychology, Institute of Psychology and Education Ulm University Ulm Germany
| | | | - Gerrit F. Blum
- Institute of Psychology and Education Ulm University Ulm Germany
| | - Sarah Wilker
- vivo international e.V. Konstanz Germany
- Department of Clinical and Biological Psychology, Institute of Psychology and Education Ulm University Ulm Germany
| | - Thomas Elbert
- Clinical Psychology and Neuropsychology, Department of Psychology University of Konstanz Konstanz Germany
- vivo international e.V. Konstanz Germany
| | - Iris‐Tatjana Kolassa
- vivo international e.V. Konstanz Germany
- Department of Clinical and Biological Psychology, Institute of Psychology and Education Ulm University Ulm Germany
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8
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Raghuraman S, Stuttard N, Hunt N. Evaluating narrative exposure therapy for post-traumatic stress disorder and depression symptoms: A meta-analysis of the evidence base. Clin Psychol Psychother 2020; 28:1-23. [PMID: 32525597 DOI: 10.1002/cpp.2486] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 05/20/2020] [Accepted: 06/03/2020] [Indexed: 11/07/2022]
Abstract
Narrative exposure therapy (NET) is an intervention for trauma spectrum disorders. Originally developed to treat refugee populations, NET has since been tested for efficacy across different settings. In this review, the NET evidence base is examined through a retrieval, synthesis and appraisal of randomized controlled trials (RCTs) published since 2002. Two independent reviewers (S. R. and N. S.) searched online databases including EMBASE, PsycINFO and PubMed. Twenty-four RCTs were selected for a meta-analysis of three outcomes: post-traumatic stress disorder (PTSD) diagnosis and PTSD and depression symptoms. All outcomes were analysed at short-term (3-4 months), midterm (6-7 months) and long-term (≥12 months) data points. A random-effects model was applied to yield standardized mean differences (SMDs) and odds ratios (ORs) as indicators of NET treatment effect. Subgroup analyses for type of trauma and type of control groups were conducted to examine potential heterogeneity. For the NET group, moderate effect sizes for PTSD symptom severity were observed at midterm and long term and at midterm for depression symptom severity. The number of PTSD diagnoses decreased significantly in the short term for the NET condition, but this was not sustained at the long term. Caution must be exercised when interpreting these results due to high heterogeneity estimates and low quality of evidence across trials. Potential small-study effects further complicate the interpretation of the findings. Recommendations are made for augmenting statistical significance research with qualitative analyses of NET efficacy to better inform clinical practice.
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Affiliation(s)
- Shruti Raghuraman
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nathan Stuttard
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nigel Hunt
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
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